John Bedson

The discordance between clinical and radiographic knee osteoarthritis: A systematic search and summary of the literature

BackgroundStudies have suggested that the symptoms of knee osteoarthritis (OA) are rather weakly associated with radiographic findings and vice versa. Our objectives were to identify estimates of the prevalence of radiographic knee OA in adults with knee pain and of knee pain in adults with radiographic knee OA, and determine if the definitions of x ray osteoarthritis and symptoms, and variation in demographic factors influence these estimates.MethodsA systematic literature search identifying population studies which combined x rays, diagnosis, clinical signs and symptoms in knee OA. Estimates of the prevalence of radiographic OA in people with knee pain were determined and vice versa. In addition the effects of influencing factors were scrutinised.ResultsThe proportion of those with knee pain found to have radiographic osteoarthritis ranged from 15–76%, and in those with radiographic knee OA the proportion with pain ranged from 15% – 81%. Considerable variation occurred with x ray view, pain definition, OA grading and demographic factorsConclusionKnee pain is an imprecise marker of radiographic knee osteoarthritis but this depends on the extent of radiographic views used. Radiographic knee osteoarthritis is likewise an imprecise guide to the likelihood that knee pain or disability will be present. Both associations are affected by the definition of pain used and the nature of the study group. The results of knee x rays should not be used in isolation when assessing individual patients with knee pain.

Sleep Disturbance and Chronic Widespread Pain

Musculoskeletal pain is common and often occurs at multiple sites. Persons with chronic widespread pain (CWP) often report disturbed sleep. Until recently, the relationship between sleep disturbance and CWP has been unclear: does poor sleep increase the risk of developing CWP, do people with CWP develop poor sleep as a consequence of their pain, or is the relationship bi-directional? In this article, we have focused on the relationship between insomnia and CWP. We briefly present descriptive epidemiological data for insomnia and CWP. We then summarise the available evidence which supports the hypothesis that the relationship is bi-directional. Finally, we discuss the clinical management of CWP and insomnia in primary care, where the vast majority of cases of CWP are managed.

How do GPs use x rays to manage chronic knee pain in the elderly? A case study

Objectives: To determine whether clinical signs and symptoms of osteoarthritis influence general practitioners’ (GPs) decisions about x raying older patients with knee pain and whether x ray reports alter their initial treatment or referral plan. Methods: A cross sectional survey of 1000 GPs in England and Wales using “paper cases” in three questionnaires mailed at two-weekly intervals. The first questionnaire assessed GPs’ management of patients with knee pain using four case scenarios, two with features of clinical knee osteoarthritis. The second questionnaire contained the same scenarios with information on x ray findings added. The third questionnaire considered management of knee pain in general. Results: 447 GPs responded to questionnaire 1, 316 (71%) to questionnaire 2, 287 (64%) to questionnaire 3. 106 responders (25%) would have x rayed all four patients and 64 (15%) none. Choosing to carry out an x ray examination was not influenced by the presence of clinical signs and symptoms of osteoarthritis but was linked to other management choices, such as referral to orthopaedics (odds ratio (OR) 2.13; 95% confidence interval (CI) 1.62 to 2.81). The strongest predictor in questionnaire 2 of a treatment or referral was whether it had been chosen in the first survey. However, the x ray report was associated with a significant change in treatment and referrals. Where radiographic osteoarthritis was present, GPs were less likely to refer to a physiotherapist (OR 0.64; 95% CI 0.50 to 0.83) or rheumatologist (OR 0.15; 95% CI 0.08 to 0.28), and more likely to refer to an orthopaedic surgeon (OR 31.34; 95% CI 21.51 to 45.66). Questionnaire 3 showed that GPs’ general views on the use of x rays correlated with the frequency of their choosing to x ray in the four individual case scenarios. Conclusions: A GP’s choice to x ray older people with knee symptoms is linked with decisions on treatment and referral even before the x ray result is known, but it does not appear to be influenced by clinical features of osteoarthritis. The presence of radiographic osteoarthritis has a marked impact on the decision to refer to secondary care. More evidence on the outcome of management without x rays is needed to help GPs in decision making.

Quality indicators for the primary care of osteoarthritis: a systematic review

Objective To identify valid and feasible quality indicators for the primary care of osteoarthritis (OA). Design Systematic review and narrative synthesis. Data sources Electronic reference databases (MEDLINE, EMBASE, CINAHL, HMIC, PsychINFO), quality indicator repositories, subject experts. Eligibility criteria Eligible articles referred to adults with OA, focused on development or implementation of quality indicators, and relevant to UK primary care. An English language restriction was used. The date range for the search was January 2000 to August 2013. The majority of OA management guidance has been published within this time frame. Data extraction Relevant studies were quality assessed using previous quality indicator methodology. Two reviewers independently extracted data. Articles were assessed through the Outcome Measures in Rheumatology filter; indicators were mapped to management guidance for OA in adults. A narrative synthesis was used to combine the indicators within themes. Results 10 853 articles were identified from the search; 32 were included in the review. Fifteen indicators were considered valid and feasible for implementation in primary care; these related to assessment non-pharmacological and pharmacological management. Another 10 indicators were considered less feasible, in various aspects of assessment and management. A small number of recommendations had no published corresponding quality indicator, such as use of topical non-steroidal anti-inflammatory drugs. No negative (‘do not do’) indicators were identified. Conclusions and implications of key findings There are well-developed, feasible indicators of quality of care for OA which could be implemented in primary care. Their use would assist the audit and quality improvement for this common and frequently disabling condition.

The effectiveness of national guidance in changing analgesic prescribing in primary care from 2002 to 2009: An observational database study

Numerous national guidelines have been issued to assist general practitioners’ safe analgesic prescribing. Their effectiveness is unclear. The objective of this study was to examine trends in general practitioners’ prescribing behaviour in relation to national guidelines.

Trends in long-term opioid prescribing in primary care patients with musculoskeletal conditions: an observational database study.

Abstract Long-term opioids may benefit patients with chronic pain but have also been linked to harmful outcomes. In the United Kingdom, the predominant source of opioids is primary care prescription. The objective was to examine changes in the incidence, length, and opioid potency of long-term prescribing episodes for musculoskeletal conditions in UK primary care (2002-2013). This was an observational database study (Clinical Practice Research Datalink, 190 practices). Participants (≥18 years) were prescribed an opioid for a musculoskeletal condition (no opioid prescribed in previous 6 months), and issued ≥2 opioid prescriptions within 90 days (long-term episode). Opioids were divided into short- and long-acting noncontrolled and controlled drugs. Annual incidence of long-term opioid episodes was determined, and for those still in a long-term episode, the percentage of patients prescribed each type 1 to 2 years, and >2 years after initiation. Annual denominator population varied from 1.25 to 1.38 m. A total of 76,416 patients started 1 long-term episode. Annual long-term episode incidence increased (2002-2009) by 38% (42.4-58.3 per 10,000 person-years), remaining stable to 2011, then decreasing slightly to 55.8/10,000 (2013). Patients prescribed long-acting controlled opioids within the first 90 days of long-term use increased from 2002 to 2013 (2.3%-9.9%). In those still in a long-term opioid episode (>2 years), long-acting controlled opioid prescribing increased from 3.5% to 22.6%. This study has uniquely shown an increase in prescribing long-term opioids to 2009, gradually decreasing from 2011 in the United Kingdom. The trend was towards increased prescribing of controlled long-acting opioids and earlier use. Further research into the risks and benefits of opioids is required.

Annual consultation incidence of osteoarthritis estimated from population-based health care data in England

Objectives. To estimate the consultation incidence of OA using population-based health care data in England and compare OA incidence figures with those derived in other countries. Methods. A population-based health care database (Consultations in Primary Care Archive) in England was used to derive the consultation incidence of OA (overall and by joint site) using the maximum available run-in period method. These estimates, and their distribution by age and sex, were compared with those published from population-based health care databases in Canada, the Netherlands and Spain. A novel age-stratified run-in period method was then used to investigate whether the consultation incidence has been increasing over time in younger adults. Results. The annual consultation incidence of OA (any joint) was 8.6/1000 persons ≥15 years of age (95% CI 7.9, 9.3) [6.3 (95% CI 5.5, 7.1) in men and 10.8 (95% CI 9.8, 12.0) in women]. Incidence increased sharply between 45 and 64 years of age, peaking at 75–84 years. The joint-specific incidence was 1.4 (95% CI 1.1, 1.7), 3.5 (95% CI 3.1, 3.9) and 1.3 (95% CI 1.1, 1.6) for hip OA, knee OA and hand OA, respectively. The estimates and their distribution by age and sex were broadly consistent with international estimates. Between 2003 and 2010, incidence in those aged 35–44 years increased from 0.3 to 2.0/1000 persons. Conclusion. Newly diagnosed cases of OA in England occur in 9 in 1000 at-risk adults each year, similar to other international estimates. Although lower, the consultation incidence proportion in younger adults appears to have increased in the past decade.

Public priorities for joint pain research: results from a general population survey

Objective. We aimed to identify the priorities for joint pain research from a large general population survey and identify characteristics associated with these priorities. Methods. A question about research priorities was developed in collaboration with the Arthritis Research UK Primary Care Centre’s Research Users’ Group. The question was embedded in a postal survey to an existing cohort of adults with self-reported joint pain, aged ≥56 years, in North Staffordshire. Respondents were asked to rank their top three priorities for research. Factor mixture modelling was used to determine subgroups of priorities. Results. In all, 1756 (88%) people responded to the survey. Of these, 1356 (77%) gave three priorities for research. Keeping active was rated the top priority by 38%, followed by research around joint replacement (9%) and diet/weight loss (9%). Two clusters of people were identified: 62% preferred lifestyle/self-management topics (e.g. keeping active, weight loss) and 38% preferred medical intervention topics (e.g. joint replacement, tablets). Those who preferred the medical options tended to be older and have hip or foot pain. Conclusion. This study has provided population data on priorities for joint pain research expressed by a large cohort of older people who report joint pain. The most popular topics for research were linked to lifestyle and self-management opportunities. Pharmaceutical and invasive interventions, despite being common topics of research, are of less importance to these respondents than non-medical topics. Specific research questions will be generated from this study with collaboration of the patient’s group.

Factors associated with primary care prescription of opioids for joint pain.

Opioids are commonly prescribed in primary care and can offer pain relief but may also have adverse effects. Little is known about the characteristics of people likely to receive an opioid prescription in primary care. The aim is to identify what factors are associated with primary care prescribing of high‐strength analgesics in a community sample of older people with joint pain.

The association between pain intensity and the prescription of analgesics and non‐steroidal anti‐inflammatory drugs

It is not known whether general practitioners (GPs) prescribe analgesic medication according to intensity of pain or a hierarchical prescribing regimen.